Yoga and Multiple Sclerosis: Maintaining engagement in physical activity

Background Physical activity is encouraged for people with Multiple Sclerosis. Yoga is a popular form of physical activity and is chosen by some people with Multiple Sclerosis. However, little is known about the impact of yoga for this population, alongside what influences ongoing engagement. Aim The aim of this study is to qualitatively explore the impact of online home-based yoga on people with Multiple Sclerosis and to explore factors that influence engagement. Methods A qualitative study using semi-structured interviews and focus groups with people with Multiple Sclerosis and a yoga teacher. Thematic analysis was used to analyse the data. Ethical Approval was gained from Northumbria University. Findings Three overarching themes emerged from the analysis. ‘Yoga as engagement in physical activity’ captured the reasoning for participating in yoga and how this method of physical activity was an alternative to physical activity done prior to diagnosis. Frustration was apparent within this theme that some individuals were unable to engage in the range of physical activity that they wished to. ‘Yoga is a personalised approach’ demonstrated the flexibility and inclusivity of yoga, for individuals with varying symptoms to be able to engage with. Finally, ‘yoga impacts individuals both physically and psychologically’ captured the focus on the psychological impact of yoga, improving wellbeing and control. Conclusions Yoga gives people with Multiple Sclerosis the feeling of control over their symptoms and a means to engage with meaningful physical activity. Prior involvement in physical activity influenced engagement in yoga and wanting to push themselves. There was reluctance among this group to engage with aerobic activity, which warrants future investigation and support from health and exercise professionals.


Introduction
in face-to-face yoga prior to COVID-19 and then participated in this online at home. All participants had carried out yoga for at least two years. The instructor sent potential participants an information sheet and consent form via email, explaining the purpose of the study. Participants were offered the opportunity to ask questions before providing written consent.

Yoga class content
The yoga style is Iyengar Yoga. The teacher aims to include all with yoga and adapt as needed with props. Poses include arm stretches, supine leg extension, hamstring stretch supine. Standing poses include triangle pose, Trikonasana and Warrior poses with the help of a wall or table behind for balance and sometimes a chair in front with the backrest facing the student. These movements can be adapted to supine. Sitting poses include legs straight, bent, crossed and backwards Virasana. Inversions include shoulder stand with a chair, keeping the weight of the body on the chair or legs on the wall or bent on a chair.

Data collection
Participants were invited to attend either a focus group or semi-structured interview. The focus group included class participants only, and two separate one-to-one semi-structured interviews were setup for class participants who were not available at this time. The instructor also participated separately in a one-to-one interview. The focus group and all interviews were carried out using Zoom Video Communications, Inc. Interviews were conducted by GWM (Health Psychologist) and GB (Biomechanist).
A topic guide was informed by a review of the literature and covered motivations to begin yoga, the impact of yoga on MS symptoms, online yoga provision, in-person yoga provision, social connections, and future delivery (Fig 1). A paper reporting the role of online yoga provision from this interview schedule has been published elsewhere [17]. Sessions lasted between 27-53 minutes. The Zoom recordings were transcribed verbatim and deleted once the transcript was produced.

Data analysis
Transcripts were uploaded into NVivo 12 (QSR International) for analysis. Braun and Clarke's reflexive, inductive Thematic Analysis was chosen as the data analysis strategy due to its theoretical freedom [19,20]. JN analysed all transcripts. Initially, the analyst immersed themselves within the transcripts before generating initial codes and subsequent themes. The potential influence of the researcher on this process, was addressed by frequent qualitative debriefing with the wider research team who have health and exercise backgrounds.

Results
Three themes were developed from the interviews and focus group (Table 1). Several subthemes contributed to each theme.
1. Yoga as engagement in physical activity. Yoga allowed individuals to engage in physical activity in a manageable way. Some participants felt unable to participate in many forms of physical activity, which was both disheartening and frustrating. Discussion of previous physical activity, whilst providing some understanding and drive for participation yoga, could be distressing for some individuals due to the feeling of not being able to be involved any longer. Yoga was considered as providing some of the participants with a workout of strength and balance as well as offering some control and choice to participate in physical activity. Participants wanted a sense of working hard and achievement from taking part in yoga.
An alternative form of physical activity. Engagement in physical activity was important to individuals. Being able to access physical activity and feeling as though people had the capability to fully partake was necessary. Accessing different forms of physical activity could be challenging at times and yoga provided a means to participate. Two participants felt that yoga provided a comparable work out to their practices in the gym.  However, it was noted that yoga was not felt to support aerobic fitness. Individuals did discuss struggling to engage with this type of exercise. This was viewed as a limitation to peoples' overall fitness, and some were unsure of how to participate in this type of physical activity.
So I consider myself to be really unfit, you know, so yoga does a lot of other things, but I am not sure how good it is for cardio.

(FGF1)
So I don't think I will be able to do it, the cardio one (P3) Previous engagement and frustration with physical activity. Participation in physical activity in the past was difficult for some individuals to discuss due to them feeling unable to engage in activities they would enjoy such as the gym or cycling. The strength to do these activities and the fatigue following had influenced some participants decision to not partake in certain types of exercise. This drive to be involved with physical activity spurred some participants to put everything into their yoga class and feel as though they were getting the best out of this. The participants with a history of attending the gym, discussed this aspect in the most detail.
(discussing the gym) Really, and I love it. I love working out and now it just kills me so much I can't do it.
(P3) (discussing a bike) I used to do it, but I don't have the strength. . .I get more frustrated because I see that I can't do it. . .

(P3)
Depending on, I mean, you know, with MS particularly you can have a really good time, I don't know about the other conditions, but you know you can have amazing energy and then you can wake up one morning and just have no energy at all. So the whole, for me doing anything like even going to a gym to get on a bicycle, you know, I am already factoring in the energy that it takes to get there. The energy it takes, because sometimes just putting your gym kit on takes a load of energy that one doesn't have.

(FGF1)
One individual discussed in detail their previous physical activity and their understanding of the positive role of exercise and physical activity on the neurophysiology of MS. This contributed to their desire to frequently practice yoga.
Yeah, me as well, because for me it was important to work out, that's how I'm used to and you know, my brother because he said, you have to keep moving he said, because you know the signal, even if it is lost all along the way because the nerves are damaged, it will look a way to and it will create new routes, but you need to you know exercise.
(P3) 2. Yoga is a personalised approach (for a diverse condition). Personalisation of yoga to individuals was key for successful engagement. This involved the teacher understanding the condition and being able to adapt poses and provide alternatives for individuals. Trust in the teacher and their ability was apparent within the interviews and the importance of this rapport that has been developed.
Variation of the condition. The variation of MS and how no two individuals experience the same symptoms was captured. Personalising the classes and ensuring an individualised approach was important to participants, as some of the poses and classes could require things that some people didn't feel they were able to do. Alongside this, how symptoms changed and presented each day could vary which needs to be taken into account when engaging in a yoga class.
I'm not that mobile. Some of the people with MS they are more mobile and everyone here has a different, you know, difficulty, but for me it's the left part, the left arm, which if they ask me to put my hand up, you see this one, to hold it straight is really kind of difficult and my posture as well. I have to be near a wall or something and when [anonymised] or some of the teachers are there Understanding of Multiple Sclerosis. The teacher and the class understanding MS was deemed of upmost importance to a number of individuals. It was important that a teacher understood the condition to personalise the yoga poses and session. Having someone who understood the nature of the condition, the variation and symptoms was also deemed key, as this would influence how much individuals felt they could be 'pushed'. Providing alternatives in yoga. Yoga was viewed as being accessible through providing alternatives such as using a chair, equipment and adapting the postures. Yoga could be viewed as requiring as standardised sequence of postures; however, both the teacher and some participants commented on the flexibility and individualised nature of these sessions and the importance of this.

Yoga impacts individuals both physically and psychologically.
Engagement in yoga and the impact on individuals psychologically was discussed in more depth and more frequently than the physical impact. Whilst there were noted physical benefits, there was less detail and focus centred around this area.
'Feel better'. The impact of yoga on some individuals' wellbeing was highlighted. Feeling better was a term frequently used to describe the effect of yoga and reasons for continued engagement. There was a sense of promoting yoga and wanting other individuals to be aware of the benefits participants described, in particular, this psychological impact. Alongside this, relaxation and breathing involved in yoga were viewed as an important element to some of the individuals. This was a technique individuals could practice at other times at home and was described as contributing to increased energy. Within the interview, the impact of fatigue and this limiting engagement in activities was highlighted, and yoga was a means to take some control of this symptom. (P3) Impact on mobility. Regular yoga practice was discussed by some of the participants as helping with their mobility including walking, joint range of movement and spasticity. This was not something that was discussed at great length within the interviews or focus groups.

Discussion
This study aimed to explore the impact of home-based yoga in pwMS and to understand engagement with this form of physical activity. Whilst there is a focus on the role of yoga supporting improvements in strength and balance [12] and other physical symptoms, there was a limited discussion of these within the interviews. The key focus was the psychological benefits pwMS found with home-based online yoga. Key for successful engagement in physical activity for pwMS is self-efficacy [21]. A recent mixed methods study for yoga with pwMS found increased self-efficacy for physical activity, in turn increasing confidence in engagement with physical activity [22]. An improved sense of wellbeing prevailed within the interviews and having a sense of control over symptoms such as fatigue, which can be a barrier to engagement in physical activity [8,23]. PwMS were able to engage with yoga with confidence, due to having this sense of control over symptoms and the ability to do this made individuals feel better and in turn continue their engagement. PwMS could use the techniques from the home-based yoga at times other than classes and found the relaxation element of yoga beneficial for wellbeing. Alongside this, an improved self-efficacy and control could be due to individualisation of the yoga, tailored to individuals' symptoms. Yoga is inherently individualised, and instructors have demonstrated knowledge of conditions such as MS [24]. The real-world application of yoga as discussed in the interviews, should be considered for future large scale trails, and ensuring this individualised nature prevails [24]. Within the interviews the knowledge of the instructor and adapting postures was highlighted as key for supporting engagement. This is an important implication for future research, consideration of the individual.
In the context of control, the use of breathing exercises was discussed by some participants. Within yoga for traumatic brain injury these breathing exercises have been found to manage stress and support individuals emotionally [25]. Alongside this, within our current study breathing was mentioned in relation to fatigue management. A pilot trail of yoga including breathing exercises for pwMS found breathing exercises improve fatigue and to influence overall wellbeing [26]. It is postulated that combined exercises, including respiratory and the upper limb may influence fatigue due to the influence of MS on respiratory dysfunction, and breathing alongside upper limb exercise as a rehabilitation strategy may influence fatigue associated with this [27]. Yoga provides a means to intrgrate these and engage in both activities.
Engagement in some form of physical activity was important to the pwMS interviewed. Whilst yoga allowed this sense of participation and control, there was frustration evident about past physical activity. Lives before and after MS have been explored in a qualitative study with pwMS [28] finding uncontrollable changes in pwMS lives and a feeling of missing out on adulthood. The current study develops these findings by considering previous physical activity engagement, as there was certainly a frustration at being unable to engage with physical activity that individuals had done in the past. PwMS identity were that of a physically active person, and this was difficult to accept having to change the type of physical activity. Identity has been shown to be important for sustaining long term engagement with physical activity [29]. This is important to consider for supporting pwMS as it was apparent those interviewed had found their identity as engaging in yoga, however for others this may be more challenging and there is the need to understand individual preferences.
Due to previous engagement in physical activity, it was important to the pwMS that the yoga felt challenging and like a workout with this giving a sense of achievement and working hard. A randomised controlled trail of yoga versus physical therapy, which included a range of strength and conditioning exercises found no difference between these groups on the influence on quality of life [30]. However, self-belief is important for sustaining physical activity behaviours in the longer term, including confidence in ability to engage with physical activity [29]. Seeing progress and feeling a physical response to the yoga provided pwMS with satisfaction and encouragement that they were able to engage with home-based yoga to a level that suited their needs. There was some despondence in the group regarding aerobic exercise. Whilst yoga was felt to support strength, aerobic exercise was felt to be missing and a challenge to engage with for those interviewed. This highlights the need for support for pwMS to enhance confidence with this type of physical activity [31] alongside yoga, as aerobic activity is a key feature of physical activity guidelines for long term conditions [10] and specifically for MS [32]. Aerobic exercise in pwMS has been shown to improve physical, mental and social functioning [13]. However, this study has identified that some pwMS, who have a past history of physical activity, and are currently engaged with yoga, have concerns about aerobic exercise. Supervised aerobic exercise programmes have shown promise in pwMS [33]. Given the value of individualised approaches and support from the home-based yoga from this interview, these elements could be integrated into aerobic interventions, as some pwMS may require guidance and support in this area, irrespective of previous engagement.
The unpredictability of MS has been found to be a challenge for pwMS [34]. With physical activity and MS, barriers can mean this feels to be not possible [35]. However, awareness of symptom variation and individual needs can support tailoring of physical activity. Within the interviews, pwMS discussed the variation in the condition both between one another and themselves day to day. The individualised nature of yoga and the ability to adapt the postures allowed pwMS with a range of symptoms to participate. This finding has also been echoed in the context of relapse to support the feeling of accomplishment and making physical activity accessible for the individual being key for engagement [31]. This individualised approach worked well with the flexibility of home-based yoga, feeling understood and safe by the teacher and peers and that something was being achieved for the individual.

Strengths and limitations
To date, there is limited qualitative exploration of the impact and engagement in yoga for pwMS. This study has provided valuable insights into what pwMS value for this type of physical activity alongside engagement being influenced by the psychological benefits felt and perceived the need to engage with physical activity. The trustworthiness of the study is enhanced through the different perspectives of the research team from different backgrounds of health and exercise influencing the qualitative analysis. Thematic analysis allows a clear audit trail of the research enhancing credibility and dependability.
This study only included pwMS who were actively involved in a home-based yoga group. Therefore, views of those who have chosen to not continue or engage with this type of exercise are not considered. Future research should aim to explore this group to further develop understanding and development of yoga for pwMS. The time of this study was during the COVID-19 pandemic, so the context of this specific time should be considered. Alongside this, the views of pwMS were from one class, with one teacher. To enhance transferability a national exploration of yoga for MS should be considered.

Conclusions
Engagement in yoga by pwMS affords individuals some control over symptoms, including fatigue, which has been demonstrated to be a barrier to engagement in physical activity for pwMS. PwMS who were physically active prior to diagnosis want to engage with meaningful physical activity, which includes feeling a sense of working hard, which links with their previous engagement with physical activity. This is an important consideration for the design of future yoga interventions for pwMS. A number of pwMS wanted to feel challenged by the physical activity. Yoga allowed pwMS to tailor the exercise to their specific needs, alongside having flexibility to engage to allow for changes in symptoms.